Diaz, Gilberto Pine View Cemetery & Crematorium
Quaker Road
Queensbury, NY 12804
(518) 745-4477 or (518) 745-4476
FUNERAL HOME:
`1r
REQUESTED RETURN TIME. 1"- 5 ?/.5 ..Je,)0�4vl_j
NAME OF FUNERAL DIRECTOR OR REGRISTERED RESIDENT DELIVERING REMAINS:
NAME: ..Cjl
DATE OF CREMATION:
Izolzb
TIME STARTED: - Z-)Sn�
------_.---------____.__ ._ _i'.. .. _.......TIME COMPLETED
TYPE OF CONTAINER: ._ - -Ql` .I' __._CQ
PLACED IN RETORT: 7 24Q ,
_..MOVED:
PLACE OF DEATH GIPas
ESTIMATED WEIGHT OF REMAINS AND CONTAINER: T
DATE & TIME REMAINS ARRIVED AT CREMATORY: 1")/
PLACED IN HOLD: Q�
PLACED IN REFRIGERATION:
RETORT # IN WHICH REMAINS WERE CREMATED:
DETAILED REASON FOR DELAY IF REMAINS WERE CREMATED MORE THAN 48 HOURS
FROM TIME OF ACCEPTED DELIVERY:
NOTE; THE CREMATION LOG SHALL 13F RETAINED IN THE PERMANENT FILE OF THE CREMATORY.
Apr 1?2C 01:38p East Eand Funeral Home In 718-547-4547 p.3
New York State
Department of State
NEWYORK Division of DIVISION CEMETERIES
STATE0F onea Commerce Plaza
OPPORTUNITY. Cemeteries Al Washington 31-00 1
Albany,NY t2231-OOQt
Telephone:(5191474-6226
ww%v.dos.ny.gov
Authorization for Cremation and Disposition
This Authorization Form must be completed and signed prior to delivery of remains for cremation.
Date:
April 16,2020 Number.
--- -
Crematory Name:Pine View Crematory
21 Quaker Road, Queensbury,NY Phone:518-745-4476
Address: —_ - -
CREMATION IS AN IRREVERSIBLE AWD FINAL PROCESS.
Cremation is carried out by placing the remains of the deceased and the container holding the remmains into a cremation chamber where i
they are subjected tc intense heat and flame. The heat and flame will incinerate and consume everything except bone and metal,'.
which are all that wig be left after cremation.
Following cremation,the crematory will take reasorable efforts to remove all of the remains and other material from the cremation
chamber,but some minimal dust and residue will likely be left behind The crematory will separate incidental and foreign material from
I the remains and the incidental and foreign material will be disposed of as required by law. The cremated remains will be mechanically
pulverizad into small pieces and placed into a designated container or urn. Cremated remains generally are pulyerlred until no
single fragment is recognizable as skeletal tissue. J
OPENING OF THE CONTAINER
The crematory may only open the container holding the un-cremated human remains in limited circumstancas,such as to confirm the
identity of the deceased or to ensure that no material is enclosed which might injure employees or damage the crematory property. If
human remains are delivered in a container which is not suitable for cremation such as ceremonial or rental casket,the
crematory will require that the remains be moved into a suitable container before it accepts the remains. The opening of a
container or the transfer or removal of remains will be conducted before a witness and vAl be done in privacy,with dignity and respect.
IDENTIFICATION OF DECEASED
Gilberto Diaz Widowed
Name of Deceased:_, Marital Status:
Madison York Assisted Living 61-80 Woodhaven Blvd.,Flushings, NY 11374
Last Known Address:
Place of Death:Glens Fails hospital
Sex: M M ®F Age: DOE:81 June 20,1938 Cate of Death:April 16,2020 Estimated Weight:��lo
Cescription of casketicontainer in which remains will be delivered.
Florence Casket Co.Minimum Cremation Casket iplywood corrugated cardooard)
PERSON IN CONTROL OF DISPOSITION
(Psrson(s)in contm,F of disposition,(nitiar ONE of the foltow0g)
1 amNJe are the designated agent of the deceased designated in a will or written instrument executed pursuant to Public
Health Law Section 4201.
�-QP-
IIVVe have no knowledge that the deceased executed a written instrument pursuant to Public Health Law Section 4201 or a
wiil containing directions for the disposition of his or her remains and Uwe are the person(s)having priority unaer Public Health Law
Sectior.4201 and have the right to authorize cremation of the remains of the deceased. MylOur relationship to the deceased is as
follows:
Gilberto Diaz
(R'aaro of GeceasedJ �- - ��
Page 1 of 3
DOS-1898-f(Rev.128115)
Apr 17 20 01:39p East Eand Funeral Home In 718-547-4547 p.4
Authorization for Cremation and Disposition
(insert from the list be!ow)
3 Surviving Child eighteen years of age cr older
Number: Description:
1. A person designated it writing pursuant to Public Health Law Section 42(11(3);
2. The surviving spouse;
2a. The surviving domestic partner;
3. Any surviving child eighteen years of age or older;
4. A surviving parent;
5. A surviving sibling eighteen years of age or older;
6. A lawfully appointed guardian;
7. Any person(s)eighteen years of age or older entitled to share in the estate and who islare closest in relationship to the decease::,
8. A duly appointed fiduciary of the estate;
9. A close friend or relative who has executed a written statement pursuant to Pubkc Health Law Section 4201(7);
10, A chief fiscal officer of a county or a public administrator appointed pursuant to the Surrogate's Court Procedure Act;
1 Oa. Any other person who is acting on behalf of the deceased and who has executed a writter statement pursuant to Public Health
Law Section4201(7).
(IMALRFE of the foBowing)
e hereby affirm that the body of the deceased does not contain a battery.battery paoK, power cell. radioactive Implant,
or radioactive device and that any such materials were removed prio-to the execution of this Authorization Form. Failure to remove
these items prior to cremation may result in harm to the crematory and crematory personnel.
1_�I affirm that instructions have been given to
Stephanie Gilman
jf=ineral Urnaetor Name)
regarding the removal of any personal property or other thing of value which any person signing below or any family member of the
Pine View Crematory _
deceased wishes to preserve. _
!Crema'o7�^�)
is not responsible for the removal of personal items from the container or from tie retrains of the deceased. Personal items left in the
container or with the remains will be destroyed by the cremation process and cannot be retrieved after cremation.
/? ,%, Pine View Crematory
ff,IfJAfe hereby authorize
���ZZZ�/// (Crematory Marvel
to cremate the remains of the deceased.
FINAL DISPOSITION
The person authorized to receive the cremated remains of the deceased from the crematory is.
Name:M.13.Kilmer Funeral Ham _Address: —
136 Main Street South Glens Fails,NY 12803 Phone 518-745-8116
--The cremated remains of deceased will be disposed of as follows:
Released to Alfred Diaz
If for any reason the person named above does riot take possession of the cremated remains,
Pine View Crematory is authorized to give possession of
�Gemaloyy Ndrw)
M B Kilmer Funerai Home __ by ceEvery
the remains to
rFbre+alMome Harrel
in person or by registered mai:.
Gilberto Diaz
- {Name o�Oaosased,'
005-1698-f(Rev.o8115) Page 2 of S
Apr 17 2C 01:39p East Eand Funeral Nome In 718-547-4547 p.5
Authorization for Cremation and Disposition
(Initial the f in�l
tVde tinoerstand that if the remains are not claimed within 120 days of cremation,
Pine View Crematcry may dispot�e of the remains in
—` --- - - - (haaw cf Grernsroryl
an irretnevable manner,such as by scattering.
CREMATION CONTAINERIURN
(Initial ONE of the following)
An um to be used as a container for the cremated remains has been purchased from
and is described as follows-_ - _ _ -- ---
Irv'Ve understand that if the um is too small to hoid the entire cremated remains,an addidonal rigid container may be used for delivery.
-OR- %%,,���//
_' / Arr um is not yet purchases. i1We understand that if ro urn is purchased or otherwise provided
pine Vie",
Crematory will place the crerna.ed remains in
'N.svw of G*arory' -
a rigid temporary con:ainer for delivery.
Stephanie Gilman _ was executed at
This Authorfzation Form waa provided by -
Fonsw!Ci,ac!or Namsl
M.B. Kilmer Funeral dome _
{Fonare,Home va reJ _
136 Main Street South Giens::allls,NY 12803
F,:nora:Fbn+a Aadressl�
and is signed by the funeral director as witness to its execution.
I,We have received a completed copy of this Authorization Form.
The person(s)identified below Isfare the person(s)in control of disposition,who by signing this Authorization Form,attest(s)
to the accuracy and completeness of the information contained In this Authorization Form and authorizes)the foregoing.
17th April 20
signed this day of
Alfred Diaz _ J
Typed or Printed Nano .
466 East Penn Street Apt 5E,New Yo-k.NY 1CCC5
fiypodor ririedNarre _ Signatvro - - -_. . -_ _--
A a0/8SS
WITNESS:
Stephanie Gillman
iFdrera.'blreeror Typed orP,inMd N&met �� !F l fire or S)grwfine,
! egistrabor ulisiir)
Gilberto Diaz
�.— --- (name ofoweased' .
DOS-1896-f(Rev 08115) Page 3 of 3